Fibroblasts in synovitis in rheumatoid arthritis but not in noninflammatory synovial tissue in meniscus lesions express the carboxyterminal domain of procollagen type I.

Synovial tissue (ST) sections from patients with rheumatoid arthritis (RA) and meniscus lesions were stained using monoclonal antibodies against the carboxyterminal domain of human type I procollagen (alpha-pC) in avidin-biotin-peroxidase complex (ABC) staining. This gave a good signal-noise ratio and identified some synovial B-type lining cells and stromal fibroblasts in inflammatory RA ST but not in noninflammatory ST from patients with meniscus lesions. The authors' findings provide immunohistochemical evidence that the local fibroblasts in inflammatory ST in RA are activated, probably as a result of various humoral mediators produced in situ (by inflammatory mononuclear cells) in RA but not in normal noninflammatory ST.

Arthrodesis in failed knee replacement in eight rheumatoid patients.

The series of eight rheumatoid patients is presented in whom arthrodesis of the knee had been performed after a failed knee replacement. Compression arthrodesis was used as a salvage procedure. The fusion rate was 75% (6/8 knees). In two patients arthrodesis was attempted three times before fusion occurred. The causes of failure are discussed. The compression technique of Charnley or Hoffman is recommended but with two frames. When the arthrodeses were properly fixed fusion seemed to occur in 2-3 months.

A comparative study of osteomyelitis and purulent arthritis with special reference to aetiology and recovery.

We analysed the records of 44 paediatric cases of acute haematogenous osteomyelitis (age 0-14 years) and 25 cases of purulent arthritis (age 0-13 years). The annual incidences were 4.5 and less than two per 100,000 children, respectively. Bacteriologic diagnosis was achieved in 82% of the acute haematogenous osteomyelitis cases and in 40% of the acute purulent arthritis cases. Staphylococcus aureus was responsible for 70% of the proven acute haematogenous osteomyelitis and acute purulent arthritis cases combined, followed by streptococci (20%) and Haemophilus influenzae (7%), which caused only acute purulent arthritis. Acute haematogenous osteomyelitis was localized in the femur in 41% of the cases and acute purulent arthritis in the knee joint in 76%. Surgery (in most cases drilling, fenestration or arthrotomy) was performed on 82% of the acute haematogenous osteomyelitis and on 32% of the acute purulent arthritis patients. Although six of the acute haematogenous osteomyelitis patients (but none of the acute purulent arthritis patients) underwent surgery for a second time, permanent damage, which was functionally non-significant, developed in only 14%. No sequelae were found in the acute purulent arthritis group. The average duration of antimicrobial therapy was 44 days in the acute haematogenous osteomyelitis group and 29 days in the acute purulent arthritis group. The prognosis for the children was similar, irrespective of whether the drugs used were staphylococcal penicillins, ampicillin, lincomycin or clindamycin.

Synovectomy of the wrist in rheumatoid arthritis and related diseases. A follow-up study of 97 consecutive cases.

Synovectomy of the wrist was done on 77 patients (97 wrists) during 1968-1981. The age of the patients at the time of operation ranged from 18 to 77 years, mean 44.9 yrs. Clinical and radiological follow-up examinations (90 wrists) or follow-up evaluation by questionnaire (7 wrists) were made by the authors in 1982. The mean length of the follow-up period was 8.5 years. Clinical symptoms of pain, swelling, restricted motion, instability and deformity of the wrist joint were evaluated and graded according to a special score. Radiological changes due to rheumatoid arthritis and osteoarthrosis were graded and analysed. Eight wrists were arthrodesed during the follow-up. Among the remaining wrists (89 cases) pain was absent or almost absent in 39%, was less than before the operation in 49% and was unchanged or worse in 12% of cases. The respective percentages for the presence of swelling were 47%, 36%, and 17%. The range of dorsiflexion was between 0 and 70 degrees, with an average of 27.9 degrees. The range of volar flexion was between 0 and 75 degrees, the mean being 28.2 degrees. The average ulnar and radial side motions were 12.9 degrees and 5.4 degrees, respectively. The radiological grading of RA remained about the same in 10 wrists and did not improve in a single wrist. In the other wrists the X-ray changes progressed. The results (patient's opinion) were subjectively good in 53%, fair in 32%, and poor in 15%.(ABSTRACT TRUNCATED AT 250 WORDS)

Arthrodesis of the wrist by internal fixation in rheumatoid arthritis: a follow-up study of forty-five consecutive cases.

Between 1972 and 1981, 59 wrists of 44 patients destroyed by rheumatoid arthritis were arthrodesed by internal fixation with a Rush pin. This study comprises 45 wrists of 38 surviving patients--nine men and 29 women, aged 20 to 72 years. The follow-up time ranged from 1 to 11 years with a mean of 3.9 years. The surgical technique used in this study is simple and safe, and a good position of the wrist in both frontal and lateral projections can easily be achieved. The Rush pin is passed down the third metacarpal and into the radius. It stabilizes the wrist adequately. All the wrists operated on obtained a strong bony fusion of the radiocarpal joint. The complication rate was low. Five of 45 Rush pins were removed because the subcutaneously located distal tip between the metacarpals irritated tendons and skin. In one male patient a thin Rush pin broke and a pseudoarthrosis of the intercarpal joints developed; there was, however, no need to remove the pin.

Fracture of the carpal scaphoid in children. A clinical and roentgenological study of 108 cases.

A series of 108 carpal scaphoid fractures in children was analysed with respect to the site, type and treatment of the fracture. The patients were followed until radiological fusion occurred. All fractures united and healed completely with conservative treatment. Ninety-four fractures, 41 of which were avulsions, were located in the distal third of the scaphoid. There were 13 waist fractures, and one avulsion fracture was located in the proximal pole of the scaphoid. The great number of avulsion fractures and the location of the fractures in the distal third of the scaphoid is very typical in children. In three neglected cases marked bone resorption was seen on the fracture surface 3 weeks after the injury. Because non-union is possible especially in neglected cases of waist fractures, control radiographs should be taken 1 or 2 weeks after the injury if the fracture is not visible on the primary radiographs but is suspected clinically. Immobilization with an adequate plaster cast is mandatory in all transverse fractures of the carpal scaphoid in children.

Classification of ankle fractures in children.

The roentgenograms of 310 children treated for ankle fractures were evaluated for grouping according to the classifications of Ashhurst-Bromer-Weber, Lauge-Hansen, and Salter-Harris. The mean age of the children at the time of injury was 11.1 years (range 2-14 years). Two hundred twenty-one (71.3%) children had malleolar fractures, 71 (22.9%) had tibial epiphyseal fractures, and 18 (5.8%) had syndesmotic lesions. The age distribution of fractures was typical: malleolar fractures predominated among the younger children, epiphyseal fractures among the older. Only the oldest children had avulsion fractures of the syndesmosis. Grouping of the fractures according to Lauge-Hansen and Ashhurst-Bromer-Weber, classifications suited to adults was largely unsuccessful. Epiphyseal fractures, moreover, were easily classified according to Salter-Harris. In spite of their complexity, ankle fractures in children can be roughly divided into avulsional and epiphyseal fractures. Adequately reduced avulsional fractures can be expected to heal well; epiphyseal fractures, however, may five rise to late complications. We propose, therefore, that ankle fractures in children be classified on the basis of roentgenological findings with respect primarily to epiphyseal lesions as well as on an additional simple grouping as to risk for clinical purposes: Group I, low risk, avulsional fractures and epiphyseal separations; Group II, high risk, fractures through the epiphyseal plate.

Fracture of the radial neck in children. A long-term follow-up study of 43 cases.

A series of 43 radial neck or head fractures in children was analysed with respect to the type of fracture and whether conservative or surgical treatment had been employed. Thirty-seven patients were examined after a follow-up period of 1-18 years (average 8 years). Tilting of the radial head, the length of the radius and the size of the radial head were measured roentgenologically to evaluate any growth disturbances. The results were good in 24, fair in 10 and poor in 3 cases. In the 14 patients treated surgically results were good in five, fair in six and poor in three cases. All but two of these patients had an angulation of the radial head of 30 degrees or more. The result was good in 20 of the 23 patients who were treated conservatively because the angulation was less than 30 degrees after reduction. In fair and poor cases the function was impaired by the limitation of motion. Disturbances in growth were generally slight, but an enlargement of the radial head was observed in 16 cases at the follow-up.

Arthrodesis of the wrist in rheumatoid arthritis. A follow-up study of 62 cases.

Two cases of pseudarthrosis of the total of 62 wrists are reported. The motion of the first, fourth and fifth C-MC joints has practical value after "subtotal" wrist arthrodesis in rheumatoid patients. The frequent non-union of the joints between the trapezium/scaphoid and around the os triquetrum was painless and without clinical significance. If the wrist was fused in a neutral position (41 wrists) the position of the index finger was increased more than five degrees in the ulnar direction at follow-up in nine hands (22%). In no single case was the change in the deviation more than five degrees in the radial direction. If the wrist was fused in the radial position more than five degrees (five cases), the change in the deviation of the index finger was correspondingly ulnar in every case. If the wrist was fused over five degrees in the ulnar position (12 cases), in four cases the index finger deviated more than five but ten degrees or less in the radial direction at follow-up compared with the position before the arthrodesis. The wrist was 15 degrees or more in the ulnar direction in each of these four cases at follow-up. The position of the wrist should be in only slight ulnar deviation, less than 10 degrees, when the angle between the radius and the second metacarpal bone is measured. Either slight dorsal flexion or the zero position are recommended.

Supracondylar fracture of the humerus in children. A long-term follow-up study of 107 cases.

A total of 107 cases of supracondylar fracture of the humerus in children were examined after a follow-up period of 8 to 18 years. No serious complications were found. Conservative treatment gave good results, and open reduction was seldom indicated. Rotational displacement and displacement in the frontal or sagittal plane remodelled by the end of the growth period, whereas tilting of the distal fragment into varus or valgus remained. The position of reduction should be checked roentgenologically until bony consolidation occurs, by measuring Baumann's angle or the carrying angle, and rereductions should be performed within 2 weeks.

Arthroplasty of the knee joint. With special reference to complications.

Ninety-one arthroplasties of the knee joint--all performed by the same orthopaedic surgeon, were followed for from 6 months to 6 years (mean 3.5 years). At the time of the primary operation the mean age of the patients, most of whom had rheumatoid arthritis, was 60 years. The prostheses most often used were the Geomedic, the modular and the polycentric. The most consistently good results were achieved with the Geomedic prosthesis. The primary arthroplasty failed in 16 knees (17.6%); deep infections developed in four knees (4.4%). In three knees the prosthesis fractured and in two knees the supporting bone fractured. All these fractures occurred in the medial compartment of the knee joint. Loosening of the prosthesis--with or without concomitant infection or fracture of the prosthesis--was the most common local complication (nine knees). Reoperations were performed, during the follow-up period reported on here, on all knees in which complications developed, except one. Eight knees, about 9%, required arthrodesis. In six knees the prosthesis was replaced, and one knee was treated by arthrotomy and closed irrigation. The four deep infections resolved during the follow-up period--one after arthrodesis of the joint and one after arthrotomy and closed irrigation. In the other two knees with deep infection the prosthesis was replaced.

Silicone rubber implant arthroplasty of the metacarpophalangeal joint in rheumatoid arthritis: a follow-up study of 32 patients.

A retrospective analysis of silicone rubber implant arthroplasty of the metacarpophalangeal joint in 32 patients with rheumatoid arthritis is reported. One hundred seven implants were followed in 37 hands for an average of 44 1/2 (12 to 120) months. Active motion of the metacarpophalangeal joint averaged 34 degrees, with a mean extension deficit of 7 degrees and a mean flexion 41 degrees. Ulnar deviation recurred to more than 10 degrees in 33 of 107 fingers (31%). Fracture of the spacer was confirmed in four joints (4%). One fracture of the proximal phalanx and one of the metacarpal head had occurred. Bone resorption around the stem or a hinge and migration of the implant were found in 26 (24%) fingers. Patient satisfaction was high; 27 patients experienced significant pain relief, the functioning of 31 hands (84%) was improved, and 28 patients (32 hands) thought that the cosmetic appearance of the hand was improved.

Acute purulent arthritis in children.

Acute purulent arthritis (APA) in children is a rare disease. A series comprising 25 children with APA seen in 1960-79 was analysed with regard to clinical problems of diagnosis and treatment. The sex ratio of boys to girls was 2.5:1. The knee joint was most commonly affected (76% of the cases). The other joints affected were the hip (16%), ankle (4%), and elbow (4%), 56% of the patients were 1-2 yr old at the onset of the disease. A bacterial etiology was established in 44% of cases; a positive culture in 36%. Staphylococcus aureus, Haemophilus influenzae, streptococci, and pneumococci were isolated. All but 2 patients received antimicrobial therapy; the duration of therapy averaged 35 days. Seven patients were treated operatively. The usual procedure was arthrotomy, and closed irrigation was performed in 2 cases only. The end result was good in all cases. There were no fatalities.

Meniscectomy in children.

The results of 42 meniscectomies in 41 children were evaluated 1 to 13 years (mean 5.6 years) after the operation. At the follow-up 11 patients (12 operated knees) had complaints. In four of these patients, all having had removel of the lateral meniscus, roentgenological examination revealed degenerative changes. The results of the clinical and roentgenological follow-up examination showed that insufficiently rigorous appraisal of the indications for surgery had led, in some cases, to unnecessary meniscectomies. The results of operations had not always been satisfactory. The reliability of arthrographic findings alone as an indication for surgery are discussed and the indications for operative treatment are presented.

The Neer II replacement for rheumatoid arthritis of the shoulder.

Thirty-eight patients had a Neer II replacement for rheumatoid arthritis of the shoulder. The average age at operation varied from 23 to 68 years. The average follow-up was 20.9 months. Forty shoulders were free of pain and function was reasonable in 21. Overall evaluation showed an excellent or satisfactory result in 15, 16, were acceptable and 10 poor. The most frequent radiological finding was upward subluxation which was present in 20 shoulders. An incomplete radiolucent zone was found around the glenoid component in 32% and around the humeral in 5%; there was no gross loosening.